Hospital to Home Transitions

When Kaiser Permanente members are transitioning home after a hospital stay, our goal at CMI is to help ensure a safe, reliable and quality return home. CMI’s ‘Transitions of Care’ initiative includes the exploration of different models of care to improve transitions, including follow-up calls, pharmacist medication reconciliation, and timely information exchange with outside organizations. All models address the following five key components of a safe transition:

  • Assessment of member and caregiver needs
  • Plan of care
  • Medication management
  • Timely exchange of health information
  • Proactive follow-up care